A nurse is performing a physical assessment for a school-age child. Which of the following actions should the nurse take?
Obtain a vertical height measurement.
Remove the child's eyeglasses before performing a visual acuity exam.
Inspect the ear by pulling the pinna down and back.
Observe abdominal movement to determine the respiratory rate.
The Correct Answer is A
A. Obtain a vertical height measurement: School-age children are measured standing upright to accurately assess linear growth and compare it with age-appropriate growth charts. Vertical height measurement reflects skeletal growth and is a key component of routine physical assessment in this age group.
B. Remove the child's eyeglasses before performing a visual acuity exam: Visual acuity testing should be performed with the child wearing corrective lenses if they are normally used. Removing eyeglasses would not reflect the child’s functional vision and may lead to inaccurate assessment findings.
C. Inspect the ear by pulling the pinna down and back: For school-age children and adults, the pinna should be pulled up and back to straighten the ear canal. Pulling the pinna down and back is appropriate only for children under 3 years of age.
D. Observe abdominal movement to determine the respiratory rate: Respiratory rate in school-age children is best assessed by observing chest movement. Abdominal observation is more appropriate in infants, who primarily use diaphragmatic breathing.
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Related Questions
Correct Answer is B
Explanation
A. Administer diuretics with the toddler's lunch: Giving diuretics with meals can increase urination, potentially disrupting rest and sleep. Timing medications to avoid frequent nighttime awakenings is important to help the toddler maintain adequate rest.
B. Establish a daily schedule with the toddler and their family: Creating a consistent daily routine helps the toddler anticipate activities and rest periods, reducing fatigue and promoting better sleep. Structured schedules are especially important for children with heart failure to balance activity and rest effectively.
C. Keep the television on in the toddler's room: Continuous television exposure can overstimulate the toddler and interfere with the ability to rest. A calm, quiet environment is more conducive to promoting restorative rest and reducing fatigue in children with heart failure.
D. Allow the toddler to visit the playroom 30 min prior to bedtime: Engaging in stimulating activities immediately before bedtime can make it harder for the toddler to fall asleep. Limiting high-energy play before rest periods supports better sleep and helps manage heart failure-related fatigue.
Correct Answer is B
Explanation
A. Disseminated disease: Disseminated tuberculosis refers to widespread infection affecting multiple organs and is diagnosed through clinical findings, imaging, and laboratory tests. A small localized induration on a tuberculin skin test does not indicate disseminated disease.
B. A negative result: An induration of 3 mm is considered negative in most populations, including school-age children without specific risk factors. Positive results generally require larger induration measurements depending on risk status, so this finding indicates no significant immune response to the test.
C. Active tuberculosis: Active tuberculosis is diagnosed based on symptoms, radiographic findings, and microbiologic evidence. A minimal induration on a tuberculin skin test alone does not confirm active disease.
D. An allergic reaction: Allergic reactions typically present with redness, itching, or swelling without firm induration. The measurement of induration, not redness, is used to interpret the tuberculin skin test result.
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